Being a good doctor is more than writing prescriptions

As doctors, we have pills to treat infections and high cholesterol. We have scalpels to replace hips and open clogged arteries. But beyond pills and scalpels, what tools do we have? Walking out of the doctor’s office without a prescription is a rare occurrence these days. And the famous surgeon tagline has always been “a chance to cut is a chance to cure.” We see people when they’re sick and we’re trained and expected to do something. But do we want more than one of every five kids and nine of ten older Americans taking prescription drugs? Do we really think that more heart stents are the secret to longevity? Of course they are if we believe our job as physicians is to treat the symptoms rather than the cause.

I’m trained in preventive medicine, one of the twenty four specialties recognized by the American Board of Medical Specialties. Out of the nearly 16,000 medical students that graduate every year, only about 120 choose preventive medicine. Does that really mean that less than one percent of doctors think preventing disease is more important than treating it? I’m afraid so. Maybe it’s because our medical culture hasn’t figured out how to profit off health, rather than sickness? Or maybe it’s because our doctors simply aren’t creative enough to think beyond pills and scalpels? Of course it’s a mixture of both and many more, but I think the main reason is we’re absolutely clueless how to treat bad lifestyle from the confines of the 8 minute office visit. It’s a horribly outdated tool for the problem at hand.

Health happens in your home and in your neighborhood, not in the exam room. Health is all the little routines you have in your life, some of them good and some of them bad. But in order to lead a wonderfully fulfilling life, we have to look at health as being the optimal mix of good food; fun movement; real relationships with people you love; financial success; a job that leverages your best skills; a neighborhood that makes health easy; and the wild card— sex, drugs, and rock & roll. I threw that last one in because health has traditionally been so burdensome and black and white. But in real life, health is grey and life is fun. And being a good doctor is much more than writing prescriptions and doing procedures, it’s about knowing your patients and inspiring them.

My first practice was strictly a house call practice where I’d see patients in their apartments here in Brooklyn and follow up with them via email or Skype. It was lean and cost $1500 to launch. I was profitable in the first month because my overhead was only about 10%. My patients paid me via PayPal and my visits were typically less than $100. I couldn’t have done any of this without my iPhone and my MacBook. I used today’s technology to practice yesteryear’s medicine. It enabled me to be real-time traveling somewhere in my neighborhood awaiting my iPhone to alert me of my next appointment. Granted, I couldn’t see 40 patients a day like other doctors. But I wanted quality, not quantity. I wanted a real relationship with good, respectful communication. And 6 to 8 house calls a day in your neighborhood gives you way more information about people than 40 harried visits in some faraway institution. But that’s just the business side of things.

Most importantly, I saw how people lived. I could see the chubby person’s potato chips on the counter, the mice droppings in the asthmatic’s ultra-cool Williamsburg loft, or the depressed person’s evidence they spent a lot of lonely time by themselves staring at glowing rectangles. My neighbors were my patients and I couldn’t walk more than two blocks without someone saying “Hey Doc!” I liked to think that every time someone said that, they were reminded about living healthier. They saw me at the farmer’s market on Saturdays, going to the gym, having barbecues in the backyard with friends, and drinking at the corner bar. I became a regular fixture in their neighborhood. Hopefully, I was this occasional little familiar nudge that inspired them to chase the good life. And if you ask me, that’s what we as doctors need to be asking ourselves the next time we write a prescription— am I inspiring or am I perpetuating a broken system?

Being a good doctor is more than writing prescriptions 14 comments

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Anonymous

Great post. Yesteryear’s medicine is coming back, house calls and all. It’s the hymns side of medicine, giving patients what they need in an environment that fosters adherence to regimens and better provider-Patirnt relationships. Congrats, Jay.

i used to lots of housecalls to elderly homebound patients, but stopped with the relatively sudden-onset of medicare note auditing for high-level visits. so no problem, i submitted the notes which stricly DID meet the coding/billing criteria set forth by medicare, but still, spotty payment and bigtime hassle. I understand this has affected all housecall billing codes in the NY area. So a couple of questions for you:

1- do you treat medicare patients, and if so, did you encounter this problem? did it impact your practice model, ie. did you start to exclude medicare patients from your practice?

2- how long is a preventive medicine fellowship, and how does this impact your treatment of patients (e.g. do you really need to see potato chip bags in the apartment of an obese patient?

nice post but still trying to see how your job is different from my prior housecall practice, where patients were truly needy and homebound, and not necessarily 30-somethings with “worried-well” syndromes.

thanks

http://twitter.com/livewellthy Stewart Segal

Excellent post! I think there are more docs vested in Preventative Med then you know. While not a specialist in PM, I’ve spent years trying to teach patients how to care for their health and live “Wellthy.” My book, “Diets and Other Unnatural Acts,” teaches how to establish a balanced lifestyle. Keep up the good work!

http://twitter.com/katellington Katherine Ellington

Glad that you are telling your story. A mentor once told me that autonomy, financial stability and prestige motivate here interest in medicine. You make exemplar use of the independent authority that physicians should have to create and advance their careers. You also make the brilliant points not often heard by practicing clinicians. We have to get to the place where we put more time, money and focus into prevention for health. Thanks for a glimpse medicine in your world.

Anonymous

I don’t mean to hijack a thread, but I have to say something
in Steve Jobs case, the average that it takes to get a NET diagnoses is about
20 years, because most doctors will dismiss it as stress. So waiting 9 months,
is an example of does one even trust doctors anymore? Most doctors are in it
for the money, and that’s all. Look at
the whole pain killer issue……

Anonymous

I’ll be honest I don’t believe doctors are in it for the
money, but it gets frustrating when doctors realy don’t know what’s going on,
and then they attack a patients assertiveness. Kind of reminds me on how
doctors killed one of our best cardiologist that we have in the area. She went
to Chesapeake hospital for chest pains
and asked for certain tests to be done, well the nurse wrote down hypochondriac
on the chart Well she had a heart attack
in the hospital and ended up dyeing, So is it her fault that she died? Should
she have been more assertive?

http://twitter.com/ElkedeQuay Elke de Quay

I would love to have such a doctor in my neighbourhood (in the Netherlands)! I do have two questions for you though:
1) I can’t help but seeing you have written this blog in the past tense; why is that?
2) What about the role of the patient: I think people nowadays believe everything can be done, fixed, created; not only in everyday life, but also (or especially) in the medical erea. The patient thus might urge the doctor ‘I’m sick, do something about it’. I think it is not only the doctor who should change, the patient has a responsibility as well! How do you think about this?

Anonymous

It is very nice and inspiring to read about somebody doing what doctors are supposed to do but has not been doing anymore, I mean not many doctors are doing anymore. We are so concerned about the science but the heart and the art of medicine are important things to make the practice worthwhile and fulfilling. Doctors should really think of options about doing house calls if needed, in addition to their office practice. And patients will appreciate it very much if they know that you can do it if they need that kind of service.

http://www.facebook.com/JEHealthCareSolutions Andy Edley

Very good article. I am glad to know that there are some doctors that are trying to help their patients change their lifestyle and take control of there health.

Daniel Beegan

My new PCP is working on reducing the number of meds I take, not adding to them, so he frequently leaves my apartment without handing me a prescription. Mind you, my former PCP was a fine doctor, but I moved 1,200 miles away. I really appreciate the house call practice, one because I don’t drive anymore because of neuro problems and secondly because it allows my doctor to see me in my own environment.

http://twitter.com/USMCShrink Kevin Nasky

Most of the work of preventative medicine is education, identifiying and overcoming barriers to lifestyle changes, etc. This all takes TIME. The fact is, that doctors can’t make the living they’re accustomed to without seeing patients Q15 or Q8, or whatever the rate is these days. If money wasn’t an option, a primary care doc would probably spend 30 minutes with patients, on average. Seeing that few patients per day would yield a salary of, what, 30-40K per year? (I’m guessing here.) Even if there were a substantial number of docs willing to work for that measly pay (there aren’t), it’d create another problem of supply/demand as doctors reduced their patient panels by 50-75%.

I think the answer probably lies in having more paraprofessionals working on the preventative/educational side. I did a med school rotation with an endocrinologist who had a nurse and a nutritionist on staff for this very purpose (of course, if the patient is seeing an endocrinologist, you can pretty much call that a prevention FAIL). I’m sure some primary care offices already have such folks on staff.

It certainly doesn’t require an MD/DO to spend the necessary time with the patients to reinforce prevenative aspects of medicine.

If a doctor is a healer, prevention and a holistic approach to health is key. In the practice of modern medicine, we dismissed all the wisdom of years gone by for pills and scalpels. It’s good to know that there is a growing shift back to treating the person as a whole.